Category Archives: Patient safety and outcomes
Charles D. Scales Jr., MD, MSHS, an alumnus of the Robert Wood Johnson Foundation/VA Clinical Scholars program (UCLA 2011-2013), is a health services researcher at the Duke Clinical Research Institute and assistant professor in the division of urologic surgery at Duke University School of Medicine. He is also assistant program director for quality improvement and patient safety for the urology residency training program at Duke University Hospital.
Young doctors training to become surgeons, also called surgical residents, are increasingly caring for patients in an environment that links quality, safety, and value to patient outcomes. Over a decade ago, the Institute of Medicine highlighted the need for improving care delivery in the landmark report, Crossing the Quality Chasm, suggesting that high-quality care should be safe, effective, patient-centered, timely, efficient (e.g., high value), and equitable. Just this week, the Institute of Medicine followed with a clarion call for training new physicians to participate in and lead efforts to continually improve both care delivery and the health of the population, while simultaneously lowering costs of care.
To support this imperative, the Accreditation Council for Graduate Medical Education, which accredits all residency training programs in the United States, mandates that all doctors-in-training receive education in quality improvement. Despite this directive, a number of substantial barriers challenge delivery of educational programs around quality improvement. Health care is increasing complex, driving residents to focus on learning the medical knowledge and surgical skills for their field. Patient care demands time and attention, which can limit opportunities to learn about quality improvement within the context of 80-hour duty limits. This barrier particularly challenges surgeons-in-training, who often spend 12 or more hours daily learning surgical skills in the operating room, leaving little time for a traditional lecture-format session about quality improvement. Finally, many surgical training programs lack faculty with expertise in the skills required to systematically improve the quality, safety, and value of patient care, since these skills were simply not taught to prior generations of surgeons.
Health care worker fatigue was a factor in more than 1,600 events reported to the Pennsylvania Patient Safety Authority, according to an analysis in the June issue of the Pennsylvania Patient Safety Advisory. Thirty-seven of those events, which occurred over a nine-year period, were categorized as harmful, with four resulting in patient deaths.
“Recent literature shows that one of the first efforts made to reduce events related to fatigue was targeted to limiting the hours worked,” Theresa V. Arnold, DPM, manager of clinical analysis for the Authority, said in a news release. “However, further study suggests a more comprehensive approach is needed, as simply reducing hours does not address fatigue that is caused by disruption in sleep and extended work hours.”
In the Pennsylvania analysis, the most common medication errors involving worker fatigue were wrong dose given, dose omission, and extra dose given. The most common errors related to a procedure, treatment, or test were lab errors. Other errors included problems with radiology/imaging and surgical invasive procedures.
More information on health care worker fatigue and patient safety is available here.
Around the country, print, broadcast, and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows, alumni, and grantees. Some recent examples:
“[D]iabetes has become a full-blown epidemic in India, China, and throughout many emerging economies,” writes Kasia Lipska, MD, an RWJF Clinical Scholars program alumna, in a New York Times opinion piece. Lipska details her experience treating patients in India, explaining that the country’s recent economic transition has created a “perfect storm of commerce, lifestyle, and genetics” that has led to a rapid growth in diabetes cases. She highlights how costly the disease is to manage, as well as the shortcomings of India’s health care infrastructure, warning that, without reforms, India will have to provide chronic care for more than 100 million diabetics in a few decades.
RWJF Scholars in Health Policy Research alumnus Michael Greenstone, PhD, co-authored an op-ed piece in the Los Angeles Times that praises a recent appellate court decision to uphold the U.S. Environmental Protection Agency’s mercury standards. The court’s majority ruled that the EPA had factored in costs when deciding how stringent the regulation should be, and that the monetized environmental benefits of the rule outweighed the costs, Greenstone writes.
A majority of Americans—69 percent—support the Affordable Care Act requirement that health insurance plans pay for birth control, according to a survey by Michelle Moniz, MD, a Clinical Scholar. The survey included more than 2,000 respondents, NBC News reports. The U.S. Supreme Court is expected to rule by June in a case in which two for-profit corporations assert that paying for insurance coverage of certain forms of birth control conflicts with the companies’ religious beliefs. Moniz’s survey was also covered by MSNBC and Newsweek, among other outlets.
Seven Days After Discharge: Studies Show Unintended Costs and Complications of Routine Surgery in the United States
New research shows that where you receive surgical care does matter, and the quality measures driving patient care may not be telling the whole story.
Supported by the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, 12 studies were selected for inclusion in the May issue of Surgery. These studies provide important insights into the risks and benefits of different procedures, fresh insights into surgical outcomes, and reasons hospitals may adopt treatment therapies despite a lack of evidence about their effectiveness.
Unintended consequences of routine surgery are greater than current measures report.
Researchers studied nearly 4 million patients treated at 1,295 ambulatory surgery centers in California, Florida, and Nebraska. While 95 percent of these patients were discharged and sent home, researchers discovered that nearly 32 out of every 1,000 patients needed hospital care within a week after leaving the ambulatory center. “Hospital transfer immediately after ambulatory surgery care is a rare event, but one week later is a far different story,” said lead author Justin P. Fox, MD, who conducted the research as an RWJF Clinical Scholar at Yale University. “The rate of ambulatory patients who need acute care after they have gone home is nearly 30 times higher and varies across centers, so it may be a more meaningful measure of assessing quality.”
Improvements to Dermatology Curriculum and Residency Training Could Improve Patient Safety, Study Finds
Modifications to curricula, systems, and teacher development may be needed to bring down medical error rates among dermatology residents, according to a study published online by JAMA Dermatology.
The survey of 142 dermatology residents from 44 residency programs in the United States and Canada draws attention to several areas of concern. According to the survey:
- Just over 45 percent of the residents failed to report needle-stick injuries incurred during procedures;
- Nearly 83 percent reported cutting and pasting a previous author’s patient history information into a medical record without confirming its validity;
- Nearly 97 percent reported right-left body part mislabeling during examination or biopsy; and
- More than 29 percent reported not incorporating clinical photographs of lesions sampled for biopsy in the medical records at their institutions.
Also, nearly three in five residents reported working with at least one attending physician who intimidates them, reducing the likelihood of reporting safety issues. More than three-quarters of residents (78 percent) have witnessed attending physicians ignoring required safety steps.
Improved patient safety and educational environments at academic medical centers were the goals of work-hour reforms adopted for first-year residents in 2011. A study published online by the Journal of Hospital Medicine shows that progress on the patient-safety front has been slow going.
Researchers examined data on patients discharged from the Johns Hopkins Hospital in Baltimore from 2008 to 2012 and analyzed safety outcomes for those seen by resident and non-resident hospitalists. The analysis revealed no significant differences—before and after the 2011 reforms that reduced the maximum length of residents’ on-duty shifts from 30 hours to 16—in areas including length of stay, 30-day readmission, inpatient mortality, ICU admission, and hospital-acquired-conditions.
The study concludes that, as noted by the Institute of Medicine, improving patient safety requires a significant focus on keeping residents’ caseloads manageable, ensuring adequate supervision of first-year residents, training residents on safe handoffs in care, and conducting ongoing evaluations of patient safety and any unintended consequences of work-hour reforms.
What drives “decision regret,” the negative cognitive emotion that occurs when an actual outcome differs from the desired or expected outcome? For nurses, fatigue is a big factor, according to a study in the current issue of the American Journal of Critical Care.
The study found that nurses impaired by fatigue, loss of sleep, daytime sleepiness, and an inability to recover between shifts are more likely than well-rested nurses to report decision regret. And while decision regret reflects previous decisions and adverse outcomes, it may also contribute to work-related stress and compromise patient safety in the future, the researchers found.
“Registered nurses play a pivotal role as members of the health care team,” lead author Linda D. Scott, RN, PhD, NEA-BC, FAAN, associate dean for academic affairs and an associate professor at the University of Illinois at Chicago College of Nursing, said in a news release. “Proactive intervention is required to ensure that critical care nurses are fit for duty and can make decisions that are critical for patients’ safety.”
Karen A. Daley, PhD, RN, FAAN, is president of the American Nurses Association. This post kicks off the “Health Care in 2014” series, in which health leaders, as well as Robert Wood Johnson Foundation scholars, grantees, and alumni share their New Year’s resolutions for our health care system and their priorities for action this year.
With so much attention focused these days on our health care system, it may not have occurred to you that the health of your own caregivers could also help determine the quality and safety of the care you receive.
Paying attention to things like getting enough rest, managing fatigue and work/life stress, living tobacco-free, taking advantage of preventive immunizations and exams, eating nutritionally and maintaining an active lifestyle and healthy weight are important for everyone. Unfortunately, nurses are often so busy caring for others that they fail to care for themselves. It is for this reason the American Nurses Association, which represents the interests of the nation's 3.1 million registered nurses (RNs), recently launched a Healthy Nurse™ program to promote healthier lifestyles and behaviors among nurses.
SreyRam Kuy, MD, MHS, is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, and a vascular surgery fellow at the Medical College of Wisconsin.
Gallbladder disease, and specifically gallstones, can present as pain in the upper abdomen, usually after eating fatty foods. More severely, gallstones can progress to an inflammation and infection called cholecystitis or cholangitis, both of which require prompt surgical treatment. Gallbladder disease is an important medical problem as it accounts for $650 billion in health care costs annually in the United States[i], making it the second most costly digestive disease in the country.[ii] With more than 700,000 cholecystectomies (surgeries to remove the gallbladder) performed annually in the United States, gallbladder disease is the number one reason for abdominal surgery in the nation.[i] Cholecystectomies can be done with traditional surgery (open cholecystectomy) or performed minimally invasively (laparoscopic cholecystectomy).
The National Health and Nutrition Examination Survey estimates 6.3 million men and 14.2 million women in the United States have gallbladder disease.[iii] It occurs two times more frequently in women than in men.[i][iv] However, during the reproductive years, women have a four-fold higher prevalence of gallstones than men.[iii] As a result of its disproportionate burden on women, gallbladder disease is a critically important topic in women’s health.
There is currently a lack of consensus on whether a patient’s gender affects how soon they get surgery for cholecystitis, what type of surgery they get (open versus laparoscopic cholecystectomy), and how they do after surgery. My prior work and that of my colleagues has clearly shown that older age negatively impacts how patients do following cholecystectomy.[v] Therefore, to determine whether gender, independent of other factors, affects outcome, we examined a national group of patients hospitalized with cholecystitis over an eight-year period, age-matched to account for the effect of age, and identified gender-based differences in patients hospitalized with cholecystitis. We measured outcomes of women compared with men who underwent cholecystectomy during that admission for cholecystitis, and identified factors associated with outcome.
Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy
By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative. This commentary originally appeared on the Institute of Medicine website.
The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.
This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.